Disparate access to nutritional food; place, race and equity in the United States

Prenatal ozone exposure and child lung function: Exploring effect modification by oxidative balance score

BACKGROUND

Prenatal exposures to ozone (O3) may impact child lung function, including through oxidative stress pathways, contributing to lifelong morbidity. Diet, reflected in oxidative balance scores (OBS), may modify these pathways and is a potential target for interventions to mitigate O3 effects.

METHODS

We examined associations between prenatal exposure to O3 and child lung function at age 8-9 years via spirometry in the CANDLE cohort within the ECHO-PATHWAYS Consortium. O3 was estimated using a point-based spatiotemporal model and averaged over fetal morphological lung development phases: pseudoglandular, canalicular, and saccular. Lung function z-scores were calculated for FEV1, FVC, FEV1/FVC, and FEF25-75. OBS during pregnancy was derived using maternal diet and lifestyle factors. Linear regression models adjusted for child, maternal, and neighborhood characteristics and exposure in other prenatal windows. Using two and three-way multiplicative interaction terms, we explored effect modification by OBS and maternal race.

RESULTS

Women (N = 661) self-identified as Black (61%), White (33%), or another race (6%); 40.7% attended some college/technical school. Mean O3 concentrations ranged from 26.1 to 29.5 ppb across exposure windows. No associations between prenatal O3 exposure and lung function were observed in primary models, although there was a suggestive adverse association of 10 ppb higher O3 in the saccular window (24-35 weeks) with lower z-scores for FEV1/FVC (-0.23, 95% CI: -0.52, 0.05) and FEF25-75 (-0.17, 95% CI: -0.43, 0.09). No effect modification by OBS or maternal race was found in two-way models. In three-way interaction models, higher O3 was associated with lower child FEV1 among Black women with lower OBS and among White women with higher OBS although data was sparse for those with the highest OBS.

CONCLUSIONS

In a large, well-characterized pregnancy cohort, we did not find robust evidence of an effect of prenatal O3 on lung function. There was suggestion of enhanced vulnerability for some subgroups in exploratory analyses.

Food retailer actions toward the National Strategy on Hunger, Nutrition, and Health to promote nutrition security: Applicability of the Business Impact Assessment-Obesity as a monitoring tool

The White House National Strategy on Hunger, Nutrition, and Health (National Strategy) encourages actions across government and society to promote nutrition security. Nutrition security includes adequate food, diet quality, and equity, and food retail settings can promote these major concepts. Of all National Strategy whole-of-society calls to action, food retailers can contribute to 15 calls as key actors. However, there is currently no standardized monitoring tool to track food retailers' commitments and actions toward the National Strategy to promote nutrition security. The Business Impact Assessment-Obesity and population-level nutrition (BIA-Obesity), a tool originally developed for corporate accountability monitoring, can be tailored for the National Strategy and nutrition security, given its standardized indicators and process to assess food company policies and commitments across six domains. We discuss the fit of the BIA-Obesity indicators for tracking food retailers' commitments and actions across four pillars of the National Strategy. Existing indicators are appropriate to monitor components of Pillar 1: Improve Food Access and Affordability; Pillar 2: Integrate Nutrition and Health; Pillar 3: Empower All Consumers to Make and Have Access to Healthy Choices; and Pillar 5: Enhance Nutrition and Food Security Research. We suggest expanding current indicators to include equity, local foods, the digital food environment, and food waste reduction to improve alignment of the BIA-Obesity with the National Strategy. Application of the BIA-Obesity as an existing tool can facilitate data cohesion and more rapid assessment of the food retailer landscape to mutually meet nutrition security goals by 2030.

Predictors of Food Insecurity and Food Assistance Program Usage Among Puerto Ricans Before and During the COVID-19 Pandemic in Holyoke, Massachusetts

BACKGROUND/OBJECTIVES

Puerto Rican households often face elevated rates of food insecurity. Frequently, households experiencing food insecurity turn to federal and emergency nutrition assistance for urgent or prolonged aid. This study analyzes factors influencing food insecurity and food assistance program involvement among Puerto Ricans in Holyoke, Massachusetts, amidst the COVID-19 pandemic.

METHODS

Using a combination of community-based participatory recruitment, purposive sampling, and web-based tools, we collected 284 survey responses. Our paper employed Pearson's chi-square, logistic regression, and hierarchical linear models to assess relationships between demographic and household attributes and food access outcomes.

RESULTS

Variables such as having children in the household and age significantly influenced food relief participation and food insecurity outcomes. Puerto Rican heritage and low educational attainment were strong predictors of obtaining federal food aid. Low-income participants disproportionately faced food shortages and depended on emergency food initiatives. Our findings indicate that demographic and household factors significantly influence food insecurity and accessibility.

CONCLUSIONS

Our study demonstrates that the pandemic made it challenging for households to obtain consistent, safe, and affordable nourishment. The impacts were unequally spread; hence, Puerto Rican communities and low-income groups were most affected.

Adherence to the Mediterranean Diet and its association with sustainable dietary behaviors, sociodemographic factors, and lifestyle: a cross-sectional study in US University students

BACKGROUND

Promoting healthy and sustainable diets is increasingly important and the Mediterranean Diet (MD) has been recognized as an appropriate example that can be adapted to different countries. Considering that the college years are the time when US young adults are most likely to adopt unhealthy eating habits, the present study assessed adherence to the MD and the sustainability of dietary behaviors in a nationally representative sample of US university students, aiming to identify crucial levers for improving their eating behaviors.

METHODS

MD adherence and the adoption of healthy and sustainable dietary patterns were assessed through the KIDMED and the Sustainable-HEalthy-Diet (SHED Index questionnaires, respectively, administered through an online survey that also included sociodemographic and behavioral questions. Non-parametric and logistic regression analyses were performed.

RESULTS

A sample of 1485 participants (median (IQR) age 21.0 (19.0-22.0); 59% women) correctly completed the survey. A medium adherence to the MD was the most prevalent (47%). According to multivariate logistic regression analysis, the likelihood of being more compliant with the MD increased when meeting physical activity recommendations, having a high SHED Index score, having the willingness to purchase and eat healthy and sustainable dishes, eating ultra-processed plant-based meat alternatives foods daily, and regularly attending the university canteen.

CONCLUSIONS

Encouraging dietary patterns rich in plant-based foods and with a moderate intake of animal products is crucial to increasing the adoption of healthy and sustainable diets, and university dining services represent a suitable setting to build a supportive environment that educates students on human and planetary health.

Nourishing the Mind: How Food Security Influences Mental Wellbeing

Food insecurity is a significant public health problem worldwide and critical to mental health. There is a complex relationship between food security and mental health. We carried out a narrative review study aiming to address how food insecurity impacts mental wellbeing by focusing on the mental health repercussions of food insecurity, recognizing its pivotal role in attaining Sustainable Development Goals 2 (on hunger) and 3 (on enhancing global wellbeing). A comprehensive search was conducted on PubMed and Google Scholar, incorporating Google searches for pertinent reports and policy documents. To address these questions, we emphasized and elucidated the interconnectedness between food security and mental health. The review shows that food security and mental health share a profound relationship influenced by multifaceted factors like socioeconomic conditions, access to nutritious food, and societal inequalities. We then provide recommendations for integrating food security into mental health strategies based on the insights and conclusions drawn. Strategies ranging from sustainable farming practices to urban agriculture initiatives and digital mental health services demonstrate avenues for enhancing food safety and mental wellbeing. This highlights the need for collaborative interdisciplinary efforts and systemic reforms to address these interconnected challenges.

The Built Environment and Pediatric Health

Buildings, parks, and roads are all elements of the "built environment," which can be described as the human-made structures that comprise the neighborhoods and communities where people live, work, learn, and recreate (https://www.epa.gov/smm/basic-information-about-built-environment). The design of communities where children and adolescents live, learn, and play has a profound impact on their health. Moreover, the policies and practices that determine community design and the built environment are a root cause of disparities in the social determinants of health that contribute to health inequity. An understanding of the links between the built environment and pediatric health will help to inform pediatricians' and other pediatric health care professionals' care for patients and advocacy on their behalf. This policy statement outlines community design solutions that can improve pediatric physical and mental health, and improve health equity. It describes opportunities for pediatricians and the health care sector to incorporate this knowledge in patient care, as well as to play a role in advancing a health-promoting built environment for all children and families. The accompanying technical report reviews the range of pediatric physical and mental health conditions influenced by the built environment, as well as historical and persistent effects of the built environment on health disparities.

Integrating human activity into food environments can better predict cardiometabolic diseases in the United States

The prevalence of cardiometabolic diseases in the United States is presumably linked to an obesogenic retail food environment that promotes unhealthy dietary habits. Past studies, however, have reported inconsistent findings about the relationship between the two. One underexplored area is how humans interact with food environments and how to integrate human activity into scalable measures. In this paper, we develop the retail food activity index (RFAI) at the census tract level by utilizing Global Positioning System tracking data covering over 94 million aggregated visit records to approximately 359,000 food retailers across the United States over two years. Here we show that the RFAI has significant associations with the prevalence of multiple cardiometabolic diseases. Our study indicates that the RFAI is a promising index with the potential for guiding the development of policies and health interventions aimed at curtailing the burden of cardiometabolic diseases, especially in communities characterized by obesogenic dietary behaviors.

A Systematic Approach to Treating Early Metabolic Disease and Prediabetes

At least 70% of US adults have metabolic disease. However, less is done to address early disease (e.g., overweight, obesity, prediabetes) versus advanced disease (e.g., type 2 diabetes mellitus, coronary artery disease). Given the burden of advanced metabolic disease and the burgeoning pandemics of obesity and prediabetes a systematic response is required. To accomplish this, we offer several recommendations: (A) Patients with overweight, obesity, and/or prediabetes must be consistently diagnosed with these conditions in medical records to enable population health initiatives. (B) Patients with early metabolic disease should be offered in-person or virtual lifestyle interventions commensurate with the findings of the Diabetes Prevention Program. (C) Patients unable to participate in or otherwise failing lifestyle intervention must be screened to assess if they require pharmacotherapy. (D) Patients not indicated for, refusing, or failing pharmacotherapy must be screened to assess if they need bariatric surgery. (E) Regardless of treatment approach or lack of treatment, patients must be consistently screened for the progression of early metabolic disease to advanced disease to enable early control. Progression of metabolic disease from an overweight yet otherwise healthy person includes the development of prediabetes, obesity ± prediabetes, dyslipidemia, hypertension, type 2 diabetes, chronic kidney disease, coronary artery disease, and heart failure. Systematic approaches in health systems must be deployed with clear protocols and supported by streamlined technologies to manage their population's metabolic health from early through advanced metabolic disease. Additional research is needed to identify and validate optimal system-level interventions. Future research needs to identify strategies to roll out systematic interventions for the treatment of early metabolic disease and to improve the metabolic health among the progressively younger patients being impacted by obesity and diabetes.

Associations of Race and Ethnicity with Hepatocellular Carcinoma, Decompensation, and Mortality in US Veterans with Cirrhosis

BACKGROUND

Among patients with cirrhosis, it remains unclear whether there are racial/ethnic differences in cirrhosis complications and mortality. We examined the associations between race/ethnicity and risk for hepatocellular carcinoma (HCC), cirrhosis decompensation, and all-cause mortality overall and by cirrhosis etiology.

METHODS

US Veterans diagnosed with cirrhosis from 2001 to 2014 (n = 120,992), due to hepatitis C virus (HCV; n = 55,814), alcohol-associated liver disease (ALD; n = 36,323), hepatitis B virus (HBV; n = 1,972), nonalcoholic fatty liver disease (NAFLD; n = 17,789), or other (n = 9,094), were followed through 2020 for incident HCC (n = 10,242), cirrhosis decompensation (n = 27,887), and mortality (n = 81,441). Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI).

RESULTS

Compared with non-Hispanic White patients, Hispanic patients had higher risk for HCC overall (aHR, 1.32; 95% CI, 1.24-1.41) and by cirrhosis etiology, particularly for ALD- (aHR, 1.63; 95% CI, 1.42-1.87) and NAFLD-cirrhosis (aHR, 1.76; 95% CI, 1.41-2.20), whereas non-Hispanic Black patients had lower HCC risk in ALD- (aHR, 0.79; 95% CI, 0.63-0.98) and NAFLD-cirrhosis (aHR, 0.54; 95% CI, 0.33-0.89). Asian patients had higher HCC risk (aHR, 1.70; 95% CI, 1.29-2.23), driven by HCV- and HBV-cirrhosis. Non-Hispanic Black patients had lower risk for cirrhosis decompensation overall (aHR, 0.71; 95% CI, 0.68-0.74) and by cirrhosis etiology. There was lower risk for mortality among all other racial/ethnic groups compared with non-Hispanic White patients.

CONCLUSIONS

Race/ethnicity is an important predictor for risk of developing HCC, decompensation, and mortality.

IMPACT

Future research should examine factors underlying these racial/ethnic differences to inform prevention, screening, and treatment for patients with cirrhosis.

The Experience of BIPOC Living with Chronic Pain in the USA: Biopsychosocial Factors that Underlie Racial Disparities in Pain Outcomes, Comorbidities, Inequities, and Barriers to Treatment

PURPOSE OF REVIEW

This review synthesizes recent findings related to the biopsychosocial processes that underlie racial disparities in chronic pain, while highlighting opportunities for interventions to reduce disparities in pain treatment among BIPOC.

RECENT FINDINGS

Chronic pain is a prevalent and costly public health concern that disproportionately burdens Black, Indigenous, and people of color (BIPOC). This unequal burden arises from an interplay among biological, psychological, and social factors. Social determinants of health (e.g., income, education level, and lack of access or inability to utilize healthcare services) are known to affect overall health, including chronic pain, and disproportionately affect BIPOC communities. This burden is exacerbated by exposure to psychosocial stressors (i.e., perceived injustice, discrimination, and race-based traumatic stress) and can affect biological systems that modulate pain (i.e., inflammation and pain epigenetics). Further, there are racial/ethnic disparities in pain treatment, perpetuating the cycle of undermanaged chronic pain among BIPOC.

Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample

Background

Disparities in acute coronary syndrome (ACS) outcomes exist between racial and ethnic groups. We aimed to evaluate disparities in resource utilization and inpatient outcomes across multiple ethnic and racial groups using contemporary data.

Methods

We identified hospital discharges for ACS in the United States using the National Inpatient Sample from 2015 to 2018. The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify variables of interest. The primary outcomes were in-hospital complications, length of stay, and total hospital charge. Statistical analysis was performed using STATA version 17.

Results

Our analysis included 1,911,869 ACS discharges. Our sample was made up of 78.6% White, 12.1% Black, and 9.3% Hispanic patients. Hispanic and Black patients presenting with ACS were younger and had more cardiometabolic comorbidities than their White counterparts, especially hypertension, diabetes mellitus, and obesity. Despite social determinants of health being more likely to be unfavorable for Hispanics than their White counterparts, they were more likely to incur higher total hospital charges than their White counterparts. Black patients were the least likely to undergo revascularization procedures. Despite these differences, White patients had higher in-hospital mortality rates than Black and Hispanic patients.

Conclusions

In this nationally representative study, despite having higher cardiometabolic comorbidity burden, lower socioeconomic status, and percutaneous intervention, Black and Hispanic patients experienced lower mortality rates than their White counterparts. Hispanic patients incurred the highest amount of total hospital charges for an ACS admission.

Intervention in Older Urban-Dwelling Veterans With Dysmobility: Protocol for a Pilot Feasibility Clinical Trial

BACKGROUND

The majority of older veterans do not meet the minimum healthy diet or physical activity recommendations despite known benefits. Identifying ways to increase adherence to programs that improve dietary quality and physical activity may reduce the risk of disability in older veterans. Peer-based interventions may be one method for facilitating lasting behavior change because peers often share a common culture and knowledge regarding problems their community experiences.

OBJECTIVE

This study aims to develop, pilot, and evaluate a theory-driven, 12-week, peer-led nutrition and exercise intervention that targets older veterans with dysmobility and assess its feasibility in 2 diverse urban areas with underrepresented populations.

METHODS

Community-dwelling veterans aged >65 years with self-reported dysmobility (defined as difficulty in at least 1 of the following: walking quickly across a street, walking a mile, ascending a flight of stairs, rising from a chair without the use of arms, or a fear of falling) from 2 Department of Veterans Affairs Geriatric Research, Education, and Clinic Centers (Baltimore, Maryland, and San Antonio, Texas) will be eligible to participate. First, this study will use validated mixed methods via web-based surveys (n=50 per site) to assess potential physical, social or environmental, and behavioral or lifestyle barriers that affect physical activity and dietary quality (phase 1). Next, we will use knowledge gained from these assessments and feedback from a focus group (n=10 per site) to adapt established Department of Veterans Affairs diet and exercise program materials to develop peer-led intervention materials and train peer leaders (n=3 per site). Finally, we will determine the feasibility and acceptability of the intervention to assess reach (recruitment and retention), adoption (satisfaction, perceived utility, attendance, and engagement), and implementation (fidelity of intervention), as well as the estimated magnitude and potential impact on selected outcomes (ie, diet quality and mobility) in 20 older veterans with dysmobility (n=10 per site).

RESULTS

The study was funded on January 1, 2022, with a projected data collection period of June 1, 2022, to December 31, 2023.

CONCLUSIONS

This study offers an innovative approach to identifying strategies that increase long-term adherence to lifestyle modification programs that improve dietary quality and physical activity in older veterans with dysmobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04994938; https://clinicaltrials.gov/ct2/show/NCT04994938.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/39192.

Using Social Media to Predict Food Deserts in the United States: Infodemiology Study of Tweets

BACKGROUND

The issue of food insecurity is becoming increasingly important to public health practitioners because of the adverse health outcomes and underlying racial disparities associated with insufficient access to healthy foods. Prior research has used data sources such as surveys, geographic information systems, and food store assessments to identify regions classified as food deserts but perhaps the individuals in these regions unknowingly provide their own accounts of food consumption and food insecurity through social media. Social media data have proved useful in answering questions related to public health; therefore, these data are a rich source for identifying food deserts in the United States.

OBJECTIVE

The aim of this study was to develop, from geotagged Twitter data, a predictive model for the identification of food deserts in the United States using the linguistic constructs found in food-related tweets.

METHODS

Twitter's streaming application programming interface was used to collect a random 1% sample of public geolocated tweets across 25 major cities from March 2020 to December 2020. A total of 60,174 geolocated food-related tweets were collected across the 25 cities. Each geolocated tweet was mapped to its respective census tract using point-to-polygon mapping, which allowed us to develop census tract-level features derived from the linguistic constructs found in food-related tweets, such as tweet sentiment and average nutritional value of foods mentioned in the tweets. These features were then used to examine the associations between food desert status and the food ingestion language and sentiment of tweets in a census tract and to determine whether food-related tweets can be used to infer census tract-level food desert status.

RESULTS

We found associations between a census tract being classified as a food desert and an increase in the number of tweets in a census tract that mentioned unhealthy foods (P=.03), including foods high in cholesterol (P=.02) or low in key nutrients such as potassium (P=.01). We also found an association between a census tract being classified as a food desert and an increase in the proportion of tweets that mentioned healthy foods (P=.03) and fast-food restaurants (P=.01) with positive sentiment. In addition, we found that including food ingestion language derived from tweets in classification models that predict food desert status improves model performance compared with baseline models that only include socioeconomic characteristics.

CONCLUSIONS

Social media data have been increasingly used to answer questions related to health and well-being. Using Twitter data, we found that food-related tweets can be used to develop models for predicting census tract food desert status with high accuracy and improve over baseline models. Food ingestion language found in tweets, such as census tract-level measures of food sentiment and healthiness, are associated with census tract-level food desert status.

Racial and Ethnic Differences in Eating Duration and Meal Timing: Findings from NHANES 2011-2018

Background: In addition to quantity and quality, meal timing and eating duration are additional dietary characteristics that impact cardiometabolic health. Given that cardiometabolic health disparities exist among racial and ethnic groups, we examined whether meal timing and eating duration are additional diet-related differences among racial and ethnic groups. Methods: Participants (n = 13,084) were adults (≥20 years) from the National Health and Nutrition Examination (NHANES, 2011−2018) Survey. Times of first and last meal and the interval between them (eating duration) were derived from two 24-h dietary recalls. Multiple linear regression analyses compared these variables among race and ethnicity after adjusting for potential confounders. Results: Compared to non-Hispanic White adults, the first mealtime was significantly later for Mexican American (23 min), Non-Hispanic Asian (15 min), Non-Hispanic Black (46 min), and Other Hispanic (20 min) and Other Racial (14 min) adults (all p < 0.05). Mexican American and Non-Hispanic Asian adults had a significantly different last mealtime by 13 min earlier and 25 min later, respectively, compared to Non-Hispanic White adults. Compared to Non-Hispanic White adults, the mean eating duration was shorter for other Hispanic (20 min), Mexican American (36 min), and Non-Hispanic Black (49 min) adults. Conclusions: Meal timing and eating duration are additional dietary characteristics that vary significantly among racial and ethnic groups.